Fire Department - This is probably the most common of all the options.
The fire department has historically been concerned with protecting life. It
has offered or provided first aid at fires or other emergencies for most of
it's existence. Most consider it only natural that the fire department increase
their training and resources to provide more advanced care for the sick or
injured. Firefighters are trained to be able to perform several jobs. Communities
started training firefighters and taking over medical care in the mid seventies.
This happened in both paid and volunteer fire departments although it may have
taken a little longer for programs to be implemented in some volunteer systems.
In these systems the fire department often responds initially AND provides
transportation to the hospital.

Some
fire departments have fought against this concept.
They don't feel that firefighters should do "double
duty". In some fire departments you will find
job divisions between trucks and engines. If you are
a "truckie" you don't work on an engine,
EVER! They can't imagine working on a MICU one day
and on an engine the next. Many of these departments
are in the more unionized states.

There
are many variations of this.

The
LA County Fire Department provides EMS and rescue through
the use of "Rescue Squads". See below.

The
Irving, Texas, Fire department has a somewhat rare
program. The fire department provides the ambulance
service.
There are two firefighters (driver rank) on the MICU,
at all times. But in addition to this, every
fire engine is also ALS equipped and will
have at least one paramedic and two EMTs at all times.
Very often you will find at least two paramedics on
all fire engines. There can be as many as four paramedics
on a fire engine on any given day. Furthermore, the
truck companies are responsible for manning the reserve
MICU's, if they are needed. This means that there are
also paramedics on the trucks. In Irving, you get at
least one paramedic, with all the necessary equipment
and medications, on virtually every call. If an MICU
and an engine is dispatched, the first arriving company
will have a paramedic, regardless of what kind of fire
apparatus it may be.
See, http://www.ci.irving.tx.us/Fire/

Private Ambulance Service - Some cities have elected to contract out
all Emergency Medical Services to private companies. This is probably the second
most popular choice. There are large nationwide companies who provide ambulance
services to communities. The state of Louisiana has a famous, statewide, service
who serves communities and rural areas. This one company employs hundreds,
if not thousands, of people. Some fire departments may consider having their
fire apparatus respond on medical calls, with the private ambulance service
as a form of having the fire department provide EMS ALSO.

It
has been brought to my attention that there is a further
division of the private EMS types of systems. This
is the type of system that is run out of hospitals.
In some communities there are ambulances that are part
of the area hospital. They are worth noting because
they do have some differences. The focus on money (or
profit) is different because of the revenue that is
received from the patient being admitted for treatment.
For this reason the EMS division often does not need
to directly show a profit. There is also, sometimes,
more
medical
oversight then you might find in other systems. The
actual differences might be slight, but probably worth
noting. Many, but not all, air ambulance services are
run by hospitals.

Note: It
is also possible for the entire fire department to
be a private enterprise. A few cities have chosen to
contract out fire and rescue services rather than use
municipal or civil service employees. The jury is still
out on this concept. The largest city ever to do this,
Scottsdale, Arizona, has just decided to abandon the
practice and go to a municipal fire department.
Story here: http://www.azcentral.com/community/scottsdale/articles/0212sr-fire12Z8.html

Note: A
variation of both of the above systems might be where
the fire department has trained medical personnel and
equipment on all apparatus and responds to all emergency
medical calls, but who contracts out to a private ambulance
service for transport. This is often referred as a "First
Responder" system. This should not be confused
with ECA training which can be called "First Responder" training
in some systems. It does not have to be an MICU or
an "Ambulance" that brings Advanced Life
Support to the patient. Some departments have dedicated
paramedic units, that are not ambulances. This is not
that unusual. LA County has done this since the early
1970's. The show "Emergency" was based upon
this department and concept. Today, 57 of the many
cities, in and around LA County, contract with the
Los Angeles County Fire Department which staffs a total
of 163 engine companies, 31 truck companies, 79 paramedic
rescue units, and numerous other pieces of specialized
apparatus. http://www.lacofd.org/

There
is a fine line between sending fire apparatus on medical
calls with the ambulance, and being able to say that
the fire department provides primary EMS and saying
that EMS is provided by a private company. Virtually
all fire departments send fire apparatus on at least
some calls. These include automobile accidents, heart
attacks, unconscious persons etc. These incidents often
require more personnel than the two people on an ambulance
can handle. An example of a city that sends fire apparatus
on all medical calls can be found in Ft. Worth, Texas.
In Ft. Worth, all firefighters are trained to the EMT
level. Some are trained as paramedics. http://www.fwfd.net/

The
Irving, Fire Department provides EMS, through
the fire department, which includes fire apparatus
responding on medical calls. But all of
Irving's engines are ALS equipped. See above.

Third Service - A few communities have elected to create a "Third
Service" for providing EMS. This means that a city has a Fire Department,
A Police Department, and an EMS department. When someone is hired for that
department, that is where they stay. Being a paramedic who decides to become
a firefighter, means starting over. The EMS personnel receive little or no
training in fire suppression operations. Austin Texas is a major example of
this concept. In 1977 the City of Austin expanded it's EMS service to include
all of Travis county. So while the fire department is a city function, EMS
is a countywide service, run by the city of Austin.
See: http://www.ci.austin.tx.us/ems/

Common
issues expressed with private or third service EMS
systems.

Some
unique problems with the Private Ambulance or Third
Service concepts do occur. One of these concerns the
living conditions and hours worked by the personnel
in each occupation. Often the medical personnel and
firefighters are housed in, or work out of, the same
buildings. Federal law allows firefighters to work
53 hours a week before paying overtime is required.
EMS workers, who are not ALSO firefighters are only
allowed to work forty hours a week before you have
to pay them overtime. This means that firefighters
will usually work 24 on/48 hours off, while EMS workers
put in something like eight hour days with rotating
night shifts. This apparently breeds resentment and
can prevent
bonds
and comradeship from forming. The two occupations sometimes
don't get along. There is also a problem because firefighters
are often paid more than private EMS workers (who appear
to work more days a month.) If you let EMS workers
work 24/48 then they get so much overtime that they
end up being paid more than firefighters. If you have
a schedule like 10/14 or 24/72 for EMS, they may only
work 40 hours a week. But this means that they receive
much less pay each week than firefighters OR they receive
the same amount for less hours. This causes problems
with shift schedules and things like eating arrangements.
You also hear of people becoming territorial about
their
jobs.
For
whatever
reasons, it's rare for these two agencies to get along.
Firefighters tend to look down upon the
EMS crews, for some reason, and the EMS people feel
like the firefighters are not 100% about patient care.
There are probably other reasons
why this just
does not seem to go smoothly. There are probably examples,
somewhere,
of this system
working well, but you don't hear of them very often.

It
is common to see a fire department take over EMS from
a private service. It is rare to see a private
service take over from a fire department. You might
see a small community decide to contract with a private
ambulance service rather than have their volunteer
fire department try to do it. But this is usually just
a
step in the town's growing process.

In
fairness, there are people who will express that EMS
has evolved past
the point where it should part of another service.
They might argue that the job or scope the fire or
police
departments
along with
the advancements in prehospital care has created a
complexity in all the jobs that deserves specialized
training. They feel that each job deserves people who
are dedicated to that job alone. Who knows what
the future may bring?

Police Department EMS - While this does occur, it is somewhat rare.
A few cities have decided to make EMS part of the police department. Here are
some examples of PD EMS. (Do you know of others?)New Castle,
Delaware Gretna, LA

The Public Safety Officer (PSO)- This person is a Police Officer,
Firefighter, and Paramedic all rolled into one. There are police officers,
in some communities, who carry firefighting gear in the back of their cars.
If a fire call comes in, they drive there and, much like Superman, change into
another role. In some systems the MICU may have the word "Police" on
the front and the paramedics carry firearms. One example of this would be DFW
Airport. With four staffed fire stations, covering 30 sq miles,
this airport is a small city. (It's larger than the island of Manhattan.) In
some
communities
people will work 24 hour shifts but break it up as 8 hours as
a police officer
on
patrol,
8
hours
as
a paramedic
in an
MICU
and 8 hours as a firefighter. This can include a change of uniform between
each job. But if a major event happens, requiring a large number of police
or firefighters, you could be detailed to do any job. In other systems there
are strange combinations of jobs and hours on duty. A person may work 10 hours
one day and 14 the next. There may be people who will work their 40 hours just
on Friday, Saturday and Sunday. The variations are endless. This system appears
to work in only the smaller communities.

Other
Types of EMS Systems

I
should also point out that there are a few state or
province run EMS systems. There are also federal or
national employees whose job it is to be firefighters
or EMS personnel. All military bases have fire departments
and so does NASA. But that is a whole different subject.
Some nations even have a national fire or EMS service.
The ambulance service in the UK is run by the National
Health Service. In many countries of the world,
the Red Cross operates any emergency ambulance service
you may encounter. You can find just about any variation
or system, you
could
think
of,
if you
look
long enough.